Self Referral Form

938 Mezzanine Dr Ste. B Lafayette, IN, 33026

Are you a mom in crisis? Please submit this form and someone from the ĒMA Team will contact you within 24-48 hours.

Known DCF Involvement? (Please check all that apply)
DCF Court Orders
Children in licensed foster care
Children in out of home placement (relative, non-relative)
Open Investigation - My children are at-risk of being removed from my care
Conflicts with Father of Children
No Social Support in Place
Criminal History
Substance Abuse History
Mental Health Disorders
Financial Crisis

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